Jose de Leon: Training psychiatrists to think like pharmacologists

Comments by Malcolm Lader

I was somewhat mystified to be asked by Tom Ban to provide some comments on the coruscating and comprehensive clinical psychopharmacology course developed by Dr. de Leon. My initial reaction was to question whether we are the appropriate body to publish this online under our imprimatur. We are primarily concerned with the History of Neuropsychopharmacology. We re-enact old battles and try to establish a verifiable record of events years ago. I wonder whether we are acting ultra vires in sponsoring this extensive teaching aid. Do we have the resources or personnel to undertake a comprehensive appraisal of Dr. de Leon’s magnum opus?  Numerous bodies such as the CINP, ECNP, ACNP and national psychopharmacology organisations run courses for training young psychopharmacologists and psychiatrists. Some national bodies supervising the training of psychiatrists also do so. I understand those in the UK are well-attended and can result in a qualification. These courses and their associated material are essentially peer-reviewed by both senior and junior colleagues. I maintain that we have a responsibility to peer-review Dr de Leon’s offering but this is in itself a daunting prospect.  I also query whether we are appropriately qualified to assess the needs of the end-user who is typically a young psychiatrist in training. We as senior psychopharmacologists have a general advisory role. Sure, we can carry out a critical assessment and sure we can do a peer review, but can we really establish whether the course fulfils the needs of the potential end users, our junior associates.

I do not wish to imply in any way that the course devised by Dr. de Leon is imperfect, incomplete or misleading. Overall I have not had the time or admittedly perhaps the motivation to review all of the extensive slides and their associated reference sources. Perhaps my colleagues in the INHN could undertake to review a particular section, for example, that concerning lithium therapy.

Notwithstanding, Dr. de Leon is modest in his claims for his expertise, to the point of diffidence. He denies that he is a psychopharmacologist but his CV and his approach to the course belie that. He covers a wide range including quite technical aspects such as pharmacokinetics.

I do question the fundamental premise that psychiatrists should be instructed to think like psychopharmacologists.  As training psychiatrists they have a much more holistic approach than most physicians as they can mobilise a wide range of skills such as interview techniques, psychology training in empathy, and neuropsychology. At the risk of inflaming susceptibilities, I exclude psychoanalytic theory in this portfolio as it is not clearly evidence-based: rather it is a collection of various sets of religious beliefs and articles of faith. Having used their particular skills and experience to establish the issues relating to a patient or client, psychiatrists should also be adept in the necessary and relevant specialist skills. If they decide to use biologically-based treatments such as those emanating from clinical pharmacology, they need an adequate grounding to evaluate evidence and to use the conclusions in a systematic and scientific way. In other words, we should train psychiatrists to think and behave like experts in the disciplines by supplementing their psychiatric expertise with knowledge from related cognate topics including neuropsychology, neurology, epidemiology, pharmacology and so on. In summary, they should think like a pharmacologist, neuropsychologist, and etc., but act like a multidisciplinary psychiatrist.

In the presentations, I welcome the extensive use of hyperlinks that allow the relevant references to be easily accessed. This saves much time in a lengthy exposition. But I do urge caution concerning the incorporation of case histories. The selection of illustrative examples is a selective process and can distort the emphasis. However, the ones I read seemed unexceptionable.

One major point for discussion relates to the role of the pharmaceutical industry in training psychiatrists and other specialists. Like other members of INHN, I have accepted numerous speaking commitments at conferences and symposia sponsored indirectly or directly by drug companies. I have assumed, perhaps somewhat naively, that my selection as a speaker by the organisers of a meeting has been uninfluenced by the financial sponsors. Even indirect sponsorship should be transparent; and it is largely so nowadays in many countries. Of course, one is under no illusions that the choice of speaker in directly-sponsored meetings is anything other than a reflection of the drug company’s appraisal that one is favourably disposed to their product. After all, the company’s function is to sell drugs, not become an educational promoter. Dr. de Leon’s CV seems mercifully remote from such commercial complications.

All in all, I welcome this initiative both for its relationship to INHN and for the quality of its content. Dr. de Leon is to be commended on his hard work. I hope it facilitates his career. But let’s see how it transpires in practice.

Malcolm Lader

July 14, 2016